Cutting Deep

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Self-injury linked to eating disorders

An alarming number of adolescents already battling eating disorders are also intentionally cutting themselves, and health-care providers may be failing to diagnose many instances of such self-injury.

A new study from Stanford University School of Medicine and Lucile Packard Children's Hospital found that 40.8 percent of patients with eating disorders in their study had documented incidents of intentionally harming themselves, most often by cutting and burning. What's more, the study suggests that inadequate clinical screening might mean the count should be much higher.

"These are very high numbers, but they're still conservative estimates," said the study's lead author, Rebecka Peebles, MD, who was an instructor in pediatrics at Stanford when the research was conducted and is joining the faculty at Children's Hospital of Philadelphia.

Peebles noted that clinicians aren't routinely asking about this activity. "We ask 97 percent of children 12 years and up if they smoke cigarettes; we need to get that good with screening for self-injurious behavior," she said.

The study is to be published online Oct. 8 in the Journal of Adolescent Health. Its senior author is James Lock, MD, PhD, professor of psychiatry and behavioral sciences and of pediatrics. He is also psychiatric director of the Comprehensive Eating Disorders Program at Packard Children's Hospital.

To conduct the study, the researchers examined the intake evaluation records of 1,432 patients, ages 10-21, who were admitted to the hospital's eating disorders program from January 1997 through April 2008. Just over 90 percent of all the patients were female, three-quarters of them white, with a mean age of 15. Among the 40.8 percent identified to be physically harming themselves, the mean age was 16. Many of these patients had a history of binging and purging, and 85.2 percent of the self-injurers were cutting themselves.

The researchers also discovered that slightly fewer than half the charts showed that health-care providers had asked patients if they intentionally injured themselves. If patients aren't asked, they are unlikely to volunteer such information, said Peebles.

Those who were questioned tended to fit previously published profiles of a self-injurer: older, white, female, suffering from bulimia nervosa, or with a history of substance abuse. "The question is, 'Are we missing other kids who are not meeting this profile?'" Peebles said. "This is part of why we wanted to look at this. If you see an innocent-looking 12-year-old boy, you don't even think of asking about self-injurious behavior. We need to get much better about universal screening."

Peebles noted that the profile itself might be flawed. If health-care workers only ask a certain type of patient about a behavior, the profile that emerges will necessarily reflect that bias, she said.

The study did not examine the reasons behind such acts but Peebles said her clinical experience suggested patients "are trying to feel pain."

"Patients describe a feeling of release that comes when they cut or burn themselves," she said. "They'll cut with a razor or a scissor blade. Sometimes we've even had kids who will take the tip of a paper clip and gouge holes. To burn themselves, they'll heat up a metal object and press it to their skin, or they'll use cigarettes."

Physicians and other health-care providers at Packard's Comprehensive Eating Disorders Program now question all new patients about self-injurious behavior. Studies have shown that between 13 and 40 percent of all adolescents engage in some form of self-injury, which is also associated with a higher risk of suicide.

"In clinical practice, kids are fairly open when you engage with them," Peebles said. "They'll come in wearing long sleeves, or hiding the marks on their inner thighs. But then when you ask them, they are usually willing to discuss the behavior."